Abdomen Radiography

1. Abdomen Radiography Abdomen Module Sean Duguay and Justin North, MD

2. Directions • View in presentation mode • This module is meant for independent study • Highlighted words in yellow have actions • Clicking on them once will identify certain areas • Clicking on them again will remove identifiers • This icon is present when there is additional information in the note section

3. Objectives • Recognize normal anatomic structures • Systematic search pattern • Recognize pathology: obstruction, free air, mass, infection/inflammation, stones • Ordering abdomen imaging - Algorithms • Adult vs. Pediatric imaging

4. Normal Anatomy Upright Abdomen Heart CT Coronal Lungs Diaphragm Stomach Liver Gallbladder Pancreas Small Intestine Ascending Colon Transverse Colon Descending Colon

5. Normal Anatomy Upright Abdomen CT Coronal Spleen Psoas Muscles Vertebral Column Aorta Inferior Vena Cava Abdomen Wall Ribs – Anterior Ribs – Posterior Kidneys

6. 1 Search Pattern Common Groupings • Bones • Stones • Gas • Mass Midline LUQ RUQ LLQ RLQ Quadrants • RUQ • RLQ • LUQ • LLQ • Midline Midline

7. Search Pattern Bones • Evaluate ribs, spine, pelvis and femurs for fracture, dislocation, subluxation, osteoarthritic changes, and lesions • Evaluate soft tissues for subcutaneous air, foreign bodies, and surgical clips

8. Search Pattern Stones • Evaluate kidneys, ureters, bladder, and urethra for opacities • Evaluate deposition of calcium in… • Arteries: aorta, iliac, renal • Organs: GB, appendix • General regions: Pelvis *Phlebolith = calcified pelvic veins commonly mistaken for urinary tract stones

9. Search Pattern Gas • Evaluate intraluminal air within stomach, GB, small intestine, large intestine, and rectum for dilatation, air-fluid levels, and bowel orientation • Evaluate extraluminal airunder diaphragm or between bowel for perforation • Evaluate periphery for subcutaneous air

10. Search Pattern Mass • Evaluate for organomegaly • Bladder • Spleen • Liver • Kidneys • Mass effect • Shadows • Psoas • Abdomen Wall

11. Search Pattern RUQ: Liver, GB, hepatic flexure, kidney, ureter RLQ: Appendix, cecum, ureter, ovary, psoas m. LUQ: Pancreas, spleen, splenic flexure, kidney, ureter, stomach, diverticulum LLQ: Diverticulum, ureter, ovary, psoas m. Midline: Spine, aorta, IVC, uterus All: Small intestine Midline LUQ RUQ LLQ RLQ Midline

12. Case 1 • 78 yo female with h/o fall c/o bilateral hip pain • Findings: • Diagnosis: - Bilateral femur fractures • Bilateral femoral cortical • defects

13. 1 Case 2 • 39 yo male with h/o left colicky pain radiating towards groin and gross hematuria • Findings: • Diagnosis: - Nephrocalcinosis • Opacification in left kidney • region

14. 1 Case 3 • 58 yo male with h/o alcoholism complains of chronic epigastric pain, occasionally radiating to back • Findings: • Diagnosis: - Chronic Pancreatitis • Punctate calcifications along • distribution of pancreas

15. Case 4 • 49 yo overweight female with h/o chronic colicky RUQ pain after meals • Findings: • Diagnosis: • - Porcelain GB likely secondary to chronic cholecystitis • - Calcification of GB wall

16. 1 Case 5 • 67 yo with h/o diffuse abdomen pain suddenly c/o right shoulder pain • Findings: • Diagnosis: - Ruptured abdominal viscus • - Air under right diaphragm • (pneumoperitoneum) Rigler’s Sign (Double Wall Sign) • - Rigler’s sign • - Safety pin likely on gown Upright Plain Film

17. 1 Case 5 (Cont…) • Which air is the free air? • - Free Air • - Not Free Air

18. 1 Case 6 • 54 yo with h/o laparotomy at age 37 for acute appendicitis develops increasingly severe abdomen pain • Findings: • Diagnosis: - Small bowel obstruction likely secondary to adhesions • Should see air in this distribution • Plicae circulares • Dilated small bowel • - Dilated loops of small bowel with visible plicae circulares • - Lack of large bowel dilation • 3,6,9 Rule (Normals) • Small Bowel < 3 cm • Large Bowel < 6 cm • Cecum < 9 cm

19. 1 Case 7 • 78 yo with h/o sudden left lower quadrant pain • Findings: • Diagnosis: - Sigmoid Volvulus • “Bent inner tube” • Or • “Coffee Bean Sign” • - Loop of dilated bowel pointing cranially • - Lack of air in rectum

20. 1 Case 8 • 64 yo male c/o hemochezia, constipation, and weight loss for 6 mo • Findings: • Diagnosis: - Colon Cancer • - Descending colon filling defect “Apple core” lesion Double Contrast Barium Enema

21. 1 Case 9 • 59 yo male with h/o alcoholism, weight loss, nausea and vomiting develops abdomen distension over last two years • Findings: • Diagnosis: • - Alcoholic hepatitis (from biopsy) • - Hepatomegaly • - Stool due to constipation • (enhanced 2o oral contrast)

22. 1 Case 10 • 51 yo female with h/o IV drug use develops abdomen distension and spider angiomata • Findings: • Diagnosis: - Viral Hepatitis (from biopsy) • - Ascites

23. 1 Case 11 • 17 yo female with h/o elevated bhcg and left flank pain • Findings: • Diagnosis: • Pregnancy • Post-renal failure 2o obstruction w/ stent placement • - Fetus • - Ureter stent Head Spine

24. Case 12 • 22 yo male with h/o RLQ pain for last twelve hours and fever • Findings: • Diagnosis: - Appendicitis • - Inflammatory changes around appendix • (fat stranding)

25. Case 13 • 69 yo with h/o constipation and occasional hematochezia c/o severe LLQ pain • Findings: • Diagnosis: - Diverticulitis • - Diverticula • - Inflammatory changes around colon diverticulum • (fat stranding)

26. Case 14 • 45 yo female with h/o recurrent kidney stones and urinary tract infections • Findings: • Diagnosis: • - Kidneys joined at midline • - Horseshoe kidney

27. Case 15 • 35 yo male with h/o cerebral aneurysm • Findings: • Diagnosis: • - Bilateral enlarged kidneys with multiple cysts • - Multiple hepatic cysts • - Polycystic Kidney Disease

28. Case 16 • 45 yo female with history of generalized abdomen pain • Findings: • Diagnosis: • Normal Adrenal Gland • Mass • Bilateral adrenal mass • Normal adrenal gland • No other acute findings • Adrenal adenoma • (most commonly identified incidentally and not clinically significant)

29. Case 17 • 18 month child with h/o painless rectal bleeding and intussusception • Findings: • Diagnosis: • Increased uptake right lower • quadrant (likely ileum) • Increased uptake in • stomach and bladder • - Meckel’s diverticulum Technetium-99m (99mTc) pertechnetate scan

30. Case 18 • Newborn male with failure to pass meconium w/in 48 hrs • Findings: • Diagnosis: • Dilated colon • No air in rectum or distal colon • - Hirschsprung’s Disease

31. Case 19 • Newborn female with h/o polyhydramnios and bilious vomiting • Findings: • Diagnosis: • Dilated stomach and proximal duodenum • - Absence of air beyond proximal duodenum • - Duodenal atresia • “Double bubble” sign

32. Case 20 • 33 yo female with h/o ulcerative colitis, jaundice, and fatigue • Findings: • Diagnosis: • Multiple intrahepatic • biliary strictures • Multiple space-occupying • defects (likely air or stones) • Primary sclerosing • cholangitis ERCP of biliary tree

33. Case 21 • 49 yo male with h/o right costophrenic tenderness and dysuria • Findings: • Diagnosis: • - Irregular hyperdensity in distribution of right kidney • - Staghorn calculus

34. Case 22 • 35 yo female with h/o smoking and oral contraceptive use • Findings: • Diagnosis: • Wedge-shaped perfusion • defect reaching periphery • - Splenic infarction

35. Intrauterine Device (IUD) • Fundus of uterine cavity • in T configuration • Indications • Contraception, emergency contraception, reduce heavy bleeding • Positioning • Malposition • Partially expelled • Malrotation • Migration

36. Ureter Stent • Stent positioned from renal • pelvis to bladder (coil seen in • both locations) • Indications • Ureteral obstruction, prophylactic, newly created ureteral anastamoses • Positioning • Complications seen on x-ray • Migration out of kidney or bladder • Stent calcification

37. IVC Filter • Inferior Vena Cava (above or • below renal veins depending on • VTE origin) • Indications • Contraindications to anticoagulation, VTE (venous thromboembolism) refractory to anticoagulation • Positioning • Complications seen on x-ray • Migration • Fragmentation

38. Endograft • Abdominal aorta +/- common • iliac arteries • Indications • Abdominal aortic or aorto-iliac aneurysms • Positioning • Complications seen on x-ray • Migration • Kinking • Fragmentation

39. References Lewis, Petra, Kitt Shaffer, Joshua Becker, Holly Gil, Mark Mullins, and Beverly Wood. "AMSER-ID Download Page." AMSER. N.p., n.d. Web. 17 Jan. 2013. <www.dartmouth.edu/~amserimages/imagedb/index.html>. Hodin, Richard. "Sigmoid volvulus." Evidence-Based Clinical Decision Support at the Point of Care | UpToDate. N.p., n.d. Web. 17 Jan. 2013. <http://www.uptodate.com/contents/sigmoid-volvulus>. Wesson, David. "Intestinal atresia." Evidence-Based Clinical Decision Support at the Point of Care | UpToDate. N.p., n.d. Web. 17 Jan. 2013. <http://www.uptodate.com/contents/intestinal-atresia>. Radswiki. "Horseshoe kidney | Image | Radiopaedia.org." Radiopaedia.org, the wiki-based collaborative Radiology resource. N.p., n.d. Web. 23 Jan. 2013. <http://radiopaedia.org/images/570782>. Gaillard, Frank, and Maxime St-Amant. "Primary sclerosing cholangitis | Radiology Reference Article | Radiopaedia.org." Radiopaedia.org, the wiki-based collaborative Radiology resource. N.p., n.d. Web. 23 Jan. 2013. <http://radiopaedia.org/articles/primary-sclerosing-cholangitis>. Gaillard, Frank. "Hirschsprung disease | Image | Radiopaedia.org." Radiopaedia.org, the wiki-based collaborative Radiology resource. N.p., n.d. Web. 23 Jan. 2013. <http://radiopaedia.org/images/148189 Gaillard, Frank, and Yuranga Weerakkody. "Meckel's diverticulum | Radiology Reference Article | Radiopaedia.org." Radiopaedia.org, the wiki-based collaborative Radiology resource. N.p., n.d. Web. 23 Jan. 2013. <http://radiopaedia.org/articles/meckels-diverticulum>. Bashir, Omar. "Endovascular aneurysm repair graft | Radiology Case | Radiopaedia.org." Radiopaedia.org, the wiki-based collaborative Radiology resource. N.p., n.d. Web. 23 Jan. 2013. <http://radiopaedia.org/cases/endovascular-aneurysm-repair-graft>. Khan, Ali N. "Pneumoperitoneum Imaging ." Pneumoperitoneum Imaging. Medscape, 18 May 2011. Web. 27 Jan. 2013.